Healthcare Provider Details

I. General information

NPI: 1457577025
Provider Name (Legal Business Name): NEIL BUCKOSH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 NE 28TH AVE STE 104
AVENTURA FL
33180-1421
US

IV. Provider business mailing address

21000 NE 28TH AVE STE 104
AVENTURA FL
33180-1421
US

V. Phone/Fax

Practice location:
  • Phone: 305-937-1999
  • Fax: 305-931-2071
Mailing address:
  • Phone: 305-937-1999
  • Fax: 305-931-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9104114
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9104114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: